Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, May 12, 2010

In a nutshell

I was given the rather difficult mission of writing 3 separate entries for a new encyclopedia. Since it hasn't been published yet I probably shouldn't be more specific but it has to do with health and stuff, obviously. Since I did all that work, I thought I'd share some of it -- but only fair use since I assigned the copyright. (It's complicated.) Here's a bit of what I had to say about physician-patient communication.

Until the mid 20th Century, the generally accepted physician-patient relationship in the West was of a nature now characterized as "benevolent paternalism." The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust and to follow "doctor's orders." During the 1970s, and with increasing prominence in the 1980s, a movement grew in medicine to promote “patient centered” care. Patient-centered interactions were defined by Lipkin et al in 1984 as treating the patient “as a unique human being with his [sic] own story to tell.” The various definitions of patient-centered care share consistency with the bio-psycho-social model for health and health care, which sees health in more than just biological terms. For example, Epstein, et al, propose that patient-centered communication must include: “1. Eliciting and understanding the patient’s perspective – concerns, ideas, expectations, needs, feelings and functioning. 2. Understanding the patient within his or her unique psychosocial context. 3. Reaching a shared understanding of the problem and its treatment . . . 4. Helping patients to share power and responsibility. . . .”

These ideals live uneasily with the reality that physician-patient encounters are asymmetrical in power, expertise, and usually in social status. After all, the reason for the encounter in the first place is that the physician has exceptional expertise. Physicians ultimately control what information they share with patients and what options they present. They monopolize the power to prescribe medications, authorize tests, and perform surgery. They have unique privileges to invade people’s bodily integrity and inquire into intimate matters that are never ordinarily discussed with strangers, or perhaps with anyone. They have immense cultural authority and prestige, and typically earn multiples of the income of their average patient.

Patients may not understand much of the vocabulary that physicians routinely use and may lack the background knowledge to accurately interpret what physicians tell them. They may be overawed by the physician’s elevated social status and reluctant or entirely unable to express doubt or objection, admit lack of understanding, or ask questions. It has been found consistently that people typically do not accurately remember or understand much of the information and instructions from physicians even immediately after a visit; and that people adhere to prescribed medication regimens only about half of the time.

The decision making heuristics of physicians and patients may be quite different. Physicians base diagnostic conclusions and treatment recommendations on biomedical theories and statistical reasoning: the probability of a beneficial outcome of an intervention versus the probability of adverse effects, weighted by the physician’s judgment of the magnitude of possible benefits and harms. Patients may not understand these calculations or may simply use other criteria, such as prior experiences of people they know, social norms of their community, shorter time horizons, idiosyncratic aversions, cost and convenience, or alternative theories of health and illness, whether from formal systems or lay conceptions. They may or may not ever discuss these criteria with their physicians.

So this is the essence, to me, of a difficult problem: How can a physician best serve the patient, and put the patient at the center of the medical encounter, given the inherent asymmetry of knowledge and power which is, after all, the point of the whole thing in the first place? It's hard work.